Definition

Cholecystitis is the inflammation of the gallbladder, which is a digestive organ responsible for storing bile. Bile plays a crucial role in emulsifying fats in food and eliminating waste products from the body. The bile is transported to the small intestine through the bile duct.

Causes

Cholecystitis can be triggered by gallstones or other factors. Gallstones form when bile in the gallbladder solidifies and forms stones. These stones can lead to intense pain if they block the bile duct, a condition known as colic pain. While this pain may subside over time, without treatment, it is likely to recur. On the other hand, blockage of bile flow due to critical conditions, major surgeries, extensive burns, sepsis (presence of bacteria in the blood triggering a strong immune response), heart attacks, sickle cell disease, Salmonella infection, diabetes mellitus, and compromised immune systems, such as in HIV/AIDS patients infected with Cytomegalovirus (CMV), Cryptosporidium, or Microsporidium, can also cause cholecystitis.

Risk factor

The risk factors for cholecystitis can be summarized with the abbreviation "5F" or "fat, female, forty, fair, fertile." This indicates that individuals at a higher risk are those who are overweight or obese (fat), females (more prone than males), over the age of 40 (with increasing risk as age advances), fair-skinned or of Scandinavian and Hispanic descent, and those in their fertile age. Additionally, sudden weight loss can elevate the risk. Conditions that lead to the rapid destruction of red blood cells, such as sickle cell disorder, can also contribute. Other factors include the presence of gallstones in the bile duct, hyperparathyroidism (increased parathyroid hormone leading to elevated blood calcium levels and the formation of calcium stones), high cholesterol levels, and tumors blocking the bile duct.

Symptoms

The symptoms of cholecystitis may include upper right or middle abdominal pain that radiates to the back or right shoulder. Additionally, the abdomen may be tender to touch. Other symptoms can include fever, nausea, and vomiting. These symptoms often occur after eating, particularly after consuming large or fatty meals.

Diagnosis

Cholecystitis is diagnosed through a medical interview, physical examination, and diagnostic tests. During the physical examination, the doctor may palpate the upper right abdomen to identify pain while the patient breathes. They may also look for signs of inflammation, such as warmth or a mass in the upper right abdomen. Body temperature is measured, and laboratory tests, including C-reactive protein (CRP) and a complete blood count (CBC), are conducted to assess signs of inflammation and elevated white blood cell count.

Imaging plays a crucial role in the diagnosis. Ultrasonography (USG) is often the initial imaging method. Computed tomography (CT) scans or magnetic resonance imaging (MRI) may be employed to evaluate conditions outside the gallbladder or complications of cholecystitis. In pregnant individuals, MRI is preferred over CT scans.

In some cases, when available, endoscopic retrograde cholangiopancreatography (ERCP) may be used. This procedure involves inserting an endoscope, a tube with a camera attached to its end, through the mouth. The tube navigates through various digestive organs until it reaches the small intestine, allowing for detailed bile duct imaging. ERCP is often employed as part of the treatment process, such as gallstone removal.

Management

Cholecystitis is a serious condition that often requires emergency medical attention. The initial management focuses on resting the intestine, ensuring adequate fluid intake, correcting electrolyte imbalances in the blood, providing analgesics for pain relief, and administering antibiotics to combat the infection-causing inflammation. If the patient's condition is stable, outpatient or at-home treatment may be considered, involving medications such as antibiotics, antiemetics, and analgesics.

In many cases, a small surgical procedure, known as laparoscopic cholecystectomy, is recommended to remove the infected or inflamed gallbladder. Recovery after this surgery is generally fast, although patients may experience difficulty digesting fatty foods, leading to bloating and diarrhea. This digestive challenge can be temporary or permanent, but most patients adapt, and the condition tends to improve over time.

If surgery is not feasible due to critical conditions, an alternative approach involves draining the gallbladder's contents out of the body using a tube attached near the skin, a procedure known as percutaneous drainage. In cases of chronic cholecystitis, dietary changes such as reducing the intake of spicy and fatty foods may be recommended to manage symptoms.

Complications

If cholecystitis is caused by infection, it can lead to the accumulation of pus within the gallbladder. In such cases, open surgery may be required to address the condition. Bacterial infections, including those caused by Escherichia coli, Clostridium perfringens, and Klebsiella, may accumulate gas on the gallbladder wall. This gas accumulation is more common in individuals with diabetes mellitus, increasing the risk of gallbladder perforation and tissue decomposition. In such critical cases, the prompt removal of the gallbladder is essential.

Another rare complication involves gallstones passing into the small intestine and accumulating, preventing adequate intestine contractions. Additionally, bacteria may enter the bloodstream, leading to sepsis, an excessive immune response, and pancreatitis, inflammation of the pancreas. 

Prevention

Preventing cholecystitis involves gradual and stable weight loss, aiming for a weekly safe rate of 0.5 to 1 kg. Maintaining a normal body weight through regulating caloric intake and regular exercise is crucial. Dietary recommendations to prevent cholecystitis include choosing low-fat, high-fiber foods such as fruits, vegetables, and whole grains.

When to see a doctor?

Seek immediate medical attention if you experience severe abdominal pain. If you cannot go alone, ask someone to accompany you to the nearest emergency room. Cholecystitis can be effectively treated when prompt medical assistance is sought, and this can be crucial in preventing complications that may lead to more serious consequences, including potential fatality.

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